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Describe the patient education and home care considerations for patients who have had thoracic surgery medications zithromax purchase combivent 100mcg mastercard. The choice of modality is based on the oxygenation disorder and whether there is a problem with gas ventilation medications related to the blood generic combivent 100mcg with visa, diffusion, or both. Therapies range from simple and noninvasive modalities (oxygen and nebulizer therapy, chest physiotherapy, breathing retraining) to complex and highly invasive treatments (intubation, mechanical ventilation, surgery). Assessment and management of the patient with respiratory disorders are best accomplished when the approach is multidisciplinary and collaborative. The goal of oxygen therapy is to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Oxygen transport to the tissues depends on factors such as cardiac output, arterial oxygen content, concentration of hemoglobin, and metabolic requirements. Hypoxemia (a decrease in the arterial oxygen tension in the blood) is manifested by changes in mental status (progressing through impaired judgment, agitation, disorientation, confusion, lethargy, and coma), dyspnea, increase in blood pressure, changes in heart rate, dysrhythmias, central cyanosis (late sign), diaphoresis, and cool extremities. Hypoxemia usually leads to hypoxia, which is a decrease in oxygen supply to the tissues. The signs and symptoms signaling the need for oxygen may depend on how suddenly this need develops. With rapidly developing hypoxia, changes occur in the central nervous system because the higher neurologic centers are very sensitive to oxygen deprivation. The clinical picture may resemble that of alcohol intoxication, with the patient exhibiting lack of coordination and impaired judgment. The need for oxygen is assessed by arterial blood gas analysis and pulse oximetry as well as by clinical evaluation. Cautions in Oxygen Therapy As with other medications, the nurse administers oxygen with caution and carefully assesses its effects on each patient. Oxygen is a medication and except in emergency situations is administered only when prescribed by a physician. Because of problems with synchrony, it is rarely used except in paralyzed or anesthetized patients. The four general types of hypoxia are hypoxemic hypoxia, circulatory hypoxia, anemic hypoxia, and histotoxic hypoxia. Hypoxemic Hypoxia Hypoxemic hypoxia is a decreased oxygen level in the blood resulting in decreased oxygen diffusion into the tissues. It may be caused by hypoventilation, high altitudes, ventilation­perfusion mismatch (as in pulmonary embolism), shunts in which the alveoli are collapsed and cannot provide oxygen to the blood (commonly caused by atelectasis), and pulmonary diffusion defects. It is corrected by increasing alveolar ventilation or providing supplemental oxygen. Circulatory Hypoxia Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Circulatory hypoxia is corrected by identifying and treating the underlying cause. Anemic Hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia because hemoglobin levels may be normal. Histotoxic Hypoxia Histotoxic hypoxia occurs when a toxic substance, such as cyanide, interferes with the ability of tissues to use available oxygen. If high concentrations of oxygen are necessary, it is important to minimize the duration of administration and reduce its concentration as soon as possible. Oxygen-induced hypoventilation is prevented by administering oxygen at low flow rates (1 to 2 L/min). Oxygen therapy equipment is also a potential source of bacterial cross-infection; thus, the nurse changes the tubing according to infection control policy and the type of oxygen delivery equipment.

Oxygen is administered to correct the hypoxemia; in some circumstances medicine cabinets surface mount buy generic combivent 100 mcg line, intubation and mechanical ventilation are necessary symptoms multiple myeloma trusted 100 mcg combivent. The patient is extremely anxious, and morphine is administered to reduce anxiety and control pain. Chapter 23 Nursing Management Management of Patients With Chest and Lower Respiratory Tract Disorders 543 Nursing management of the patient with pulmonary edema includes assisting with administration of oxygen and intubation and mechanical ventilation if respiratory failure occurs. These include musculoskeletal disorders (muscular dystrophy, polymyositis), neuromuscular junction disorders (myasthenia gravis, poliomyelitis), some peripheral nerve disorders, and spinal cord disorders (amyotrophic lateral sclerosis, Guillain-Barrй syndrome, and cervical spinal cord injuries). These conditions, which may cause respiratory failure, usually are produced by an underlying lung disease, pleural disease, or trauma and injury. A mismatch of ventilation to perfusion is the usual cause of respiratory failure after major abdominal, cardiac, or thoracic surgery. Acute Respiratory Failure Respiratory failure is a sudden and life-threatening deterioration of the gas exchange function of the lung. It exists when the exchange of oxygen for carbon dioxide in the lungs cannot keep up with the rate of oxygen consumption and carbon dioxide production by the cells of the body. The absence of acute symptoms and the presence of a chronic respiratory acidosis suggest the chronicity of the respiratory failure. Patients with these disorders develop a tolerance to the gradually worsening hypoxemia and hypercapnia. Clinical Manifestations Early signs are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and finally respiratory arrest. Medical Management the objectives of treatment are to correct the underlying cause and to restore adequate gas exchange in the lung. Intubation and mechanical ventilation may be required to maintain adequate ventilation and oxygenation while the underlying cause is corrected. These disorders impair the normal response of chemoreceptors in the brain to normal respiratory stimulation. The nurse implements strategies (eg, turning schedule, mouth care, skin care, range of motion of extremities) to prevent complications. A characteristic feature is arterial hypoxemia that does not respond to supplemental oxygen. On chest x-ray, the findings are similar to those seen with cardiogenic pulmonary edema and present as bilateral infiltrates that quickly worsen. The acute lung injury then progresses to fibrosing alveolitis with persistent, severe hypoxemia. The patient also has increased alveolar dead space (ventilation to alveoli, but poor perfusion) and decreased pulmonary compliance ("stiff lungs," which are difficult to ventilate). Clinically, a patient is thought to be in the recovery phase if the hypoxemia gradually resolves, the chest x-ray improves, and the lungs become more compliant (Ware & Matthay, 2000). This results in leakage of fluid into the alveolar interstitial spaces and alterations in the capillary bed. Alveoli collapse because of the inflammatory infiltrate, blood, fluid, and surfactant dysfunction. Small airways are narrowed because of interstitial fluid and bronchial obstruction. The lung compliance becomes markedly decreased (stiff lungs), and the result is a characteristic decrease in functional residual capacity and severe hypoxemia. The blood returning to the lung for gas exchange is pumped through the nonventilated, nonfunctioning areas of the lung, causing a shunt to develop. This means that blood is interfacing with nonfunctioning alveoli and gas exchange is markedly impaired, resulting in severe, refractory hypoxemia. Assessment and Diagnostic Findings Intercostal retractions and crackles, as the fluid begins to leak into the alveolar interstitial space, are evident on physical examination.

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Census Bureau projects that by the year 2030 treatment as prevention discount 100mcg combivent mastercard, there will be more people older than 65 years of age (22%) than people younger than 18 years of age (21%) symptoms kidney stones purchase combivent 100 mcg overnight delivery. As the older population increases, the number of people who live to be very old will also increase. Health professionals will be challenged to design strategies that address the higher prevalence of illness within this aging population. Many chronic conditions commonly found among older people can be managed, limited, and even prevented. Older people are more likely to maintain good health and functional independence if appropriate community-based support services are available. According to data from the National Vital Statistics System, in 1998 a 75-year old man could be expected to live until the age of 85, and a 75-year old woman could be expected to live until the age of 87 (National Center for Health Statistics, 2000). By 2030, people older than 65 years of age will account for 22% of the population, compared with 13% in 2001. Because many of the baby boomers (those born between 1940 and 1960) tended to have children later in life, these children will face the competing demands of caring for their aging parents while caring for their own dependent children (Spillman, 2001). Data from year 1900 to present is used to predict millions of Americans aged 65 and older in the year 2030. Chronic disease is the major cause of disability, and heart disease, cancer, and stroke continued to be the three most significant causes of death in persons 65 years of age and older in the United States between 1980 and 1998 (Table 12-1). Medicare funding covered 32% of the costs of hospital services and 22% of the costs of physician services in the United States in 1998. Nursing home care, in contrast, was financed primarily by Medicaid (46%) and out-of-pocket payments (33%) (National Center for Health Statistics, 2000). The advice and services of a competent attorney regarding financial and personal issues can preserve future autonomy and self-determination. The nurse as an advocate can encourage the older person to prepare advance directives for future decision making in the event of incapacitation (Plotkin & Roche, 2000). A power of attorney is a legal agreement that authorizes a designated person to act in specific, outlined circumstances on behalf of the signer. This is a form of voluntary guardianship, permission for which is freely granted when the older person is competent. Unless stated otherwise, a power of attorney is invalidated on the incapacity of the signer. A durable power of attorney is a similar agreement that continues even if the older person is disabled or incapacitated. This power can include the authorization to make financial or personal decisions, depending on the desires of the signer (Chart 12-1). In a trust, the person designates someone to manage his or her property, stipulates how and under what circumstances the property will be managed, and designates a beneficiary. If no advance arrangement has been made, and the older person appears unable to make decisions, anyone can petition the court for a competency hearing. If the court rules that the person is incompetent, the judge will appoint a guardian-a third party who is given powers by the court to assume responsibility for making financial or personal decisions for that person. There are two kinds of guardians: guardian of the person and guardian of the estate. Because such a court action strips the civil liberties and constitutional rights from the older person, a potential for great harm exists. Safeguards include the following: (1) the older person must be given notice, (2) he or she must be given an Chapter 12 opportunity to be legally represented, and (3) medical testimony can be cross-examined. A less restrictive form of guardianship, called limited guardianship, transfers to the appointed guardian only those powers or duties that the older person cannot exercise. This written document must be signed by the person and by two witnesses; a copy should be given to the physician and incorporated into the medical record. The person must understand that this document is not meant to be used only when certain (or all) types of medical treatment are withheld; rather, it allows for a detailed description of all health care preferences, including full use of all available medical interventions. In both settings, however, the documentation and placement of advance directives in the medical record varies considerably from facility to facility, as does the education of patients about advance directives.

Less common causes are heat stroke treatment goals for anxiety proven 100mcg combivent, near-drowning in sea water (which contains a sodium concentration of approximately 500 mEq/L) treatment yeast in urine buy discount combivent 100mcg line, and malfunction of either hemodialysis or peritoneal dialysis proportioning systems. Clinical Manifestations the clinical manifestations of hypernatremia are primarily neurologic and are presumably the consequence of cellular dehydration (Adrogue & Madias, 2000a). Clinically, these changes may be manifested by restlessness and weakness in moderate hypernatremia and by disorientation, delusions, and hallucinations in severe hypernatremia. Dehydration (resulting in hypernatremia) is often overlooked as the primary reason for behavioral changes in the elderly patient. If hypernatremia is severe, permanent brain damage can occur (especially in children). Brain damage is apparently due to subarachnoid hemorrhages that result from brain contraction. Thirst is so strong a defender of serum sodium levels in healthy people that hypernatremia never occurs unless the person is unconscious or is denied access to water. Flushed skin, peripheral and pulmonary edema, postural hypotension, and increased muscle tone and deep tendon reflexes are additional signs and symptoms of hypernatremia. Body temperature may rise mildly but returns to normal when the hypernatremia is corrected. For patients taking lithium, the nurse observes for lithium toxicity, particularly when sodium is lost by an abnormal route. Because diuretics promote sodium loss, patients taking lithium are instructed not to use diuretics without close medical supervision. Actual fluid needs are determined by evaluating fluid intake and output, urine specific gravity, and serum sodium levels. Administering sodium to a patient with normovolemia or hypervolemia predisposes the patient to fluid volume overload. As stated previously, the nurse must monitor patients with cardiovascular disease very closely. In severe hyponatremia, the aim of therapy is to elevate the serum sodium level only enough to alleviate neurologic signs and symptoms. It is generally recommended that the serum sodium concentration be raised no higher than 125 mEq/L (125 mmol/L) with a hypertonic saline solution. Assessment and Diagnostic Findings In hypernatremia, the serum sodium level exceeds 145 mEq/L (145 mmol/L) and the serum osmolality exceeds 295 mOsm/kg (295 mmol/L). The urine specific gravity and urine osmolality are increased as the kidneys attempt to conserve water (provided the water loss is from a route other than the kidneys) (Fall, 2000). It can be caused by a gain of sodium in excess of water or by a loss of water in excess of sodium. With a water loss, the patient loses more water than sodium; as a result, the serum Medical Management Hypernatremia treatment consists of a gradual lowering of the serum sodium level by the infusion of a hypotonic electrolyte solution (eg, 0. Many clinicians consider a hypotonic sodium solution to be safer than D5W because it allows a gradual reduction in the serum sodium level and thereby decreases the risk of cerebral edema. A rapid reduction in the serum sodium level temporarily decreases the plasma osmolality below that of the fluid in the brain tissue, causing dangerous cerebral edema. There is no consensus about the exact rate at which serum sodium levels should be reduced. For example, alterations in its concentration change myocardial irritability and rhythm. Potassium imbalances are commonly associated with various diseases, injuries, medications (diuretics, laxatives, antibiotics), and special treatments, such as parenteral nutrition and chemotherapy (Cohn et al. To maintain potassium balance, the renal system must function because 80% of the potassium is excreted daily from the body by way of the kidneys; the other 20% is lost through the bowel and in sweat. The kidneys are the primary regulators of potassium balance and accomplish this by adjusting the amount of potassium that is excreted in the urine. As serum potassium levels increase, so does the potassium level in the renal tubular cell.

References:

• https://www.nhlbi.nih.gov/sites/default/files/media/docs/COPD%20National%20Action%20Plan%20508_0.pdf
• http://dpanther.fiu.edu/sobek/content/FI/15/05/25/74/00001/Ingram%20et%20al_2013_Climate%20of%20the%20Southeast%20United%20States.pdf
• https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
• https://www.cdc.gov/wisewoman/docs/ww_technical_assistance_guidance.pdf
• https://www.lexjansen.com/pharmasug/2017/SS/PharmaSUG-2017-SS02.pdf